Safeguarding and quality in commissioning care homes

Proportionate responses

Key points for commissioners

Commissioners work with local safeguarding leads to ensure that multi-agency policy and procedures:

support proportionate responses to abuse alerts
promote agreed understanding of good safeguarding practice among all partners
are clear about when it is, and is not, appropriate for a provider to lead an investigation.

Commissioners work with local safeguarding leads to ensure care homes can demonstrate that:

they are following multi-agency procedures
responses to alerts are based on good decision making and proportionality and that the process is transparent
they understand what constitutes a ‘complaint’ and what should be treated as a ‘safeguarding alert’
they are clear about what is poor, acceptable and best practice in safeguarding based on the Essential Standards of Quality and Safety.

Commissioners work with local safeguarding leads to ensure:

that care homes cannot evict people as a result of them complaining about the service
the quality of internal investigations and outcomes is monitored
that data from investigations is utilised to improve safeguarding responses.

It is important that the response to a safeguarding alert is in proportion to the alleged incident. For example, an allegation that one resident has stolen £5 from another would not warrant the same level of response as an allegation of rape. Many authorities have provided some guidance by way of ‘response levels’ within their multi-agency procedures. Commissioners, with support from their safeguarding lead, should ensure that providers are consistently making good decisions that are person-centred and proportionate.

Overzealous responses could result in reluctance to raise concerns for residents and staff. Multi-agency procedures should make clear when providers should raise an alert and what information should be shared between the commissioner, the provider and CQC. Risk assessment processes should be integral to this process.

The person who is at risk of or experiencing abuse should be at the centre of the decision making process in safeguarding procedures and should understand the reasons for decisions they do not agree with. If a person lacks the capacity to make decisions about their safety, their family or close friends should be included in decisions about their best interests. If there are no family or friends, an Independent Mental Capacity Advocate should be appointed.

Responding to allegations of abuse, neglect and harmOpen

Leading the investigation

In most cases following the referral, the provider should be in a position to carry out an investigation into alleged abuse, neglect or harm. There may be cases where it is better for an external investigator to be appointed: for example, this may be the case for a family-run business where institutional abuse is alleged, or where the manager or owner of the service is implicated. The circumstances where an external investigator would be required should be set out in the local multi-agency procedures. All investigators should have received appropriate training.

Following local guidance

In the event that abuse, neglect or harm happens or is suspected, providers should be bound by contractual agreements to follow the safeguarding policy and procedures of the local authority in which they are situated. If there are cross-border complications regarding responsibilities, reference should be made to the ADASS cross boundary protocol (PDF).

Staff suspension

The cost of paying staff who are suspended for long periods of time due to protracted police and local authority investigations can be an issue for providers, especially small providers with limited resources. Such situations are often outside the provider’s control. It may therefore be helpful to discuss in advance, and include in the contract if appropriate, when it may be reasonable for the commissioner to share a proportion of this financial burden.

Dealing with malicious alerts

Malicious alerts by disgruntled staff members, residents or their relatives can cause significant problems for providers and can impact significantly on employees who are wrongfully accused. Employees can be affected both professionally and personally. They can become isolated from colleagues and friends at work and there may be long-term impacts such as depression, loss of self esteem and impact on career progression.

There should be a prompt response to all allegations, not least to minimise the effect on the organisation and the individuals involved. Clear processes for dealing with allegations as set out in local multi-agency procedures, as well as thorough scrutiny of evidence, will help to identify those that are malicious. Investigators should be aware when considering witness statements that there may also be malicious intent on the part of witnesses.

If it is decided that there is no case to answer and there is suspicion that the allegation is malicious, this should be stated and the reasons recorded. If it can be evidenced that their intent was malicious, the person making the allegation should be subject to appropriate disciplinary procedures. Attempts to discredit the organisation with false information could be deemed gross misconduct under the terms of their contract.

Dealing with multiple alerts

Where numerous concerns are raised about a service in a short period of time, it is important that there is a prompt, well coordinated and efficient response from the safeguarding team and commissioners in partnership with CQC. Contracts should include an agreed framework for dealing with multiple alerts. The priority must be the safety of residents in the home.

Institutional abuse may be the underlying cause of multiple alerts. ‘Institutional abuse occurs when the routines, systems and regimes of an institution result in poor or inadequate standards of care and poor practice which affects the whole setting and denies, restricts or curtails the dignity, privacy, choice, independence or fulfilment of adults at risk’ (SCIE, 2010). Institutional abuse has been identified by stakeholders as one of the most commonly occurring safeguarding issues in residential care.

In order to ensure that environments that may bring about institutional abuse are not tolerated, commissioners should ensure that staff are well trained, supervised and supported. Quality assurance processes should assess the quality of management and ensure there are adequate staffing levels and person-centred practice.

Organisational culture is often responsible for institutional abuse, neglect and harm. Commissioners should ensure that employees have information about whistleblowing and the external support available from Public Concern at Work and other organisations such as unions.

Commissioners must work to prevent institutionalised practice in the first place and, if it is identified, they should in the first instance address it and identify how it has developed to inform future commissioning practice. A knee-jerk response to place an embargo on admissions should be avoided as this can have a negative impact on the wellbeing of existing residents. An embargo can bring about financial difficulties for the home, in some cases threatening closure. This could force people to move when they do not want to and could lead to a shortage of provision in the area. Bowman (2010) argues that ‘safeguarding referrals are being used as a regulatory lever’ and highlights that ‘the consequent diminished income may jeopardise investment in service development.’ Commissioners should make every effort to work with the provider to address the issues in the first instance.

Embargo on placements

In cases where standards in a home are of grave concern and quality is consistently poor despite help and support, it may be necessary for commissioners to stop placing people in the home until it improves. In certain circumstances where providers are failing to meet essential standards, CQC may also put restrictions on placements to a home.

An embargo should only be considered as a last resort where there are serious and ongoing concerns about the safety of residents which cannot be addressed by any other means. Commissioners should have offered all possible support and assistance to the organisation to help them improve prior to taking such serious action. The safety of existing residents should be prioritised by all concerned.

Decisions not to make further placements in a home should be clear and transparent for the service provider and for the purposes of scrutiny. A silent embargo, where a decision not to make further placements is not communicated to the provider, is not acceptable practice. The policy for placing an embargo should be agreed as part of the contract and this should include a policy for information sharing with residents and relatives and other authorities funding places in the home. The reputation of a care home should not be based on hearsay or opinion. Only facts should be shared in an open transparent way.

Commissioners need to recognise the impact an embargo will have on a home's business and potential ongoing viability. They must be clear about the objectives of issuing the embargo and the conditions under which it will be lifted: there should be a clear plan of action for the short term and for long-term monitoring once it is lifted.

In exceptional circumstances, and where all other avenues have been exhausted, there may be a need to decommission services. In such circumstances, the needs of people using the service should be paramount. To some residents, the risks related to moving may be high. Older people in particular may not cope well with being moved without proper preparation and every effort should be made to ensure individuals remain in control and have choice about what happens to them. Best Interests meetings, including the relevant family members or friends (and in their absence an Independent Mental Capacity Advocate) and professionals, should be held for those unable to make decisions about moving as the consequence of a home closure.